Assessment Of Peripheral Vascular Disease Research Articles

Pilot study to investigate differences in middle molecules, oxidative stress and markers of peripheral vascular disease in patients treated by high flux haemodialysis and haemodiafiltration.

BackgroundDialysis patients have an increased risk of mortality. Recently treatment with haemodiafiltration (HDF) has been reported to reduce mortality, particularly cardiovascular mortality, compared to standard high-flux haemodialysis (HD). However, why HDF may offer a survival advantage remains to be determined. So, we conducted a pilot study to explore differences in middle-molecules, inflammation and markers of vascular disease in patients treated by HD and HDF.MethodsObservational cross-sectional study measuring serum β2-microglobulin (β2M), Advanced Glycosylation End Products (AGEs) by skin autofluorescence (SAF), oxidative stress with ischaemia modified albumin ratio (IMAR) and peripheral vascular disease assessment using Ankle-Brachial Index (ABI), and arterial stiffness using Cardio-Ankle Vascular Index (CAVI).ResultsWe studied 196 patients, mean age 69.1 ± 12.4 years, 172 (87.8%) treated by HD and 24 (12.2%) by HDF. Age, body mass index, co-morbidity and dialysis vintage were not different between HD and HDF groups. Middle molecules; β2M (31±9.9 vs 31.2±10 ug/mL) and SAF (2.99±0.72 vs 3.0±0.84 AU), ABI (1.06±0.05 vs 1.07±0.10) and CAVI (9.34±1.55 vs 9.35±1.23) were not different, but IMAR was higher in the HD patients (38.4±14.8 vs 31.3 ± 17.4, P = 0.035)ConclusionsIn this pilot observational study, we found patients treated by HDF had lower oxidative stress as measured by IMAR, with no differences in middle molecules. Lower oxidative stress would be expected to have diverse protective effects on the cardiovascular system Although we found no differences in ABI and CAVI, future studies are required to determine whether reduced oxidative stress translates into clinically relevant differences over time.

Assessment of Peripheral Vascular Disease by Physical Therapists.

Assessment of Peripheral Vascular Disease by Physical Therapists.

Abstract 325: Usefulness of Peripheral Vascular Disease Assessment on Readmission in a Heart Failure Program Cohort

Background: Peripheral arterial disease (PAD) was reported to have a relationship with functional capacity in heart failure patients. Heart failure patients presenting with a good functional capacity have been found to have better metabolic equivalents (METs). Recognizing and managing patients’ functional capacity surrogates like ankle-brachial index (ABI) and METs will be beneficial to improve the rate of readmission, however, little is known about the relationship with readmission rate in heart failure patients. We assessed readmission rate within 30 days after discharge using functional capacity assessment. Methods: 860 patients who were followed in the cardiology clinic from 2005 to 2015 were included. We analyzed the 240 patients who were admitted with a diagnosis of acute heart failure. Patients who were unable to cardiac rehabilitation or who had severe lung disease were excluded. Heart failure is classified as a reduced ejection fraction (HFrEF, EF <40) and preserved ejection fraction (HFpEF, EF>=50). MET (Metabolic equivalents) level was used for functional capacity. If ABI was less than 0.9 or over 1.4, patients were regarded to have peripheral arterial disease.We found no significant difference between our HFpEF and HFrEF patients (Mean METS 7.5±0.6 vs 7.4±0.7). ABI did not show any significant difference (1.1±0.2 vs 1.0±0.3). In multiple logistic regression analyses, HFpEF patients with more than 4 MET level were likely to have fewer readmissions rate compared to HFpEF patients with less than 4 METS level [odds ratio (OR): 0.54, confidence interval (CI): 0.35-0.81]. HFpEF patients with ABI between 0.9 and 1.4 had less readmission rate compared to HFpEF with less than 0.9 or more than 1.4 ABI [OR: 0.62, CI: 0.41-0.77] after related risk factors adjustment. Conclusion: In conclusion, good functional status with better METs and ABI in HFpEF patients was significantly associated with less readmission rate. ABI might be a surrogate factor for assessing functional capacity in HFpEF patients. This result implies that heart failure patients’ functional capacity might need to be assessed to decrease readmission rate.

Graded Exercise Therapy and Six Minute Walk Test: The Modern Care of Peripheral Vascular Disease

Peripheral vascular disease (PVD) is a serious condition characterized by obstruction of large arteries in the lower extremity. PVD is one of the leading causes of morbidity in the elderly population; affects their lifestyle and daily practice. Claudication is the primary symptom, defined as cramping in the calf, thigh and hips while doing leg exercises like walking, and climbing stairs. Risk factors are very similar to ischemic heart disease (IHD) including smoking, diabetes mellitus, dyslipidemia, and hypertension. Symptoms and history assessment are significant as are duration of discomfort, pain score and family history. Arteriography, ankle/brachial index (ABI), Doppler ultrasound and CT angiography are the procedures to confirm the PVD. Treadmill stress test (TMT), resting ankle index (RAI) and post-occlusive reactive hyperemia (PORH) are used to determine the diagnostic accuracy. Diet control is an essential step to managing hypertension, high cholesterol, and high sugar. Six-minute walk test is done for functional assessment of PVD. Six-minute walk test is a well-validated measure of walking endurance which doesn’t need any specific training or sophisticated equipment or laboratory. A baseline six-minute walk test has been found to predict rates of mobility loss, all-cause mortality and cardiovascular disease mortality among the patients with PVD. Graded exercise therapy (GET) is a physical activity that starts very slowly and gradually an increase over time. All kind of steps and stretches directly or indirectly improve the lifestyle and morbidity of patients after interventions. Exercise adherence shows long-term success in its kind of patients.

Clinical Study of Peripheral Arterial Disease in Lower Limbs

Background: Peripheral arterial disease (PAD) is part of a global vascular problem of diffuse atherosclerosis. PAD patients die mostly of cardiac and cerebrovascular-related events and much less frequently due to obstructive disease of the lower extremities. Aggressive risk factors modification is needed to reduce cardiac mortality in PAD patients. Aim and objectives: To study the frequency of risk factors in peripheral vascular disease, To study the clinical presentations of peripheral vascular disease, To study the imaging modalities in assessment of peripheral vascular disease, To study the responsiveness of medical therapy for this disorder. Results: It is a prospective clinical study of 50 cases of peripheral vascular disease, who are presenting to Department of Surgery, Dr.PSIMS & RF over a period of 2 years from October’2013 to September’ 2015, which included 50 admitted cases in different surgical units picked randomly and study was conducted. Atherosclerosis accounted for 80% of these cases and was found to be the commonest cause of lower limb ischemia in this region. TAO accounted for 20% and was the next common cause of lower limb ischemia. 82% cases were associated with diabetes mellitus. Conclusion: Peripheral vascular disease is a common surgical problem with most of the population being males and among them mainly involving the smokers. Presentation was mainly claudication pain and minor percent presented with rest pain. Arterial Doppler is a specific investigation for peripheral vascular disease Patients if present early in the disease process medical line of management like exercise, antiplatelet medication, cholesterol lowering medication and drugs like Cilostazol, pentoxiphylline have been prescribed and followed. If limb salvage was planned minor procedures like debridement, ray amputation are sufficient. If they present late in the disease process Major procedures like below knee amputation and above knee

High-permittivity thin dielectric pad improves peripheral non-contrast MRA at 3T

Background Non-contrast magnetic resonance angiography (NC-MRA) is an alternative diagnostic tool for assessment of peripheral vascular disease in patients with impaired kidney function. While peripheral NC-MRA based on subtraction of two turbo-spin-echo acquisitions may benefit from increased signal-to-noise ratio (SNR) at 3T, it also suffers from signal loss in the right femoral artery due to B1 inhomogeneities[1], which can be minimized using highpermittivity dielectric pads[2]. The purpose of this study was to utilize high-permittivity dielectric pad to reduce NC-MRA signal loss associated with B1 inhomogeneity.

Does quality of care for hypertension in primary care vary with postcode area deprivation? An observational study

BackgroundHypertension is a common major risk factor for stroke and coronary heart disease. Little is known about how achievement of financially incentivised and non-incentivised indicators of quality of care varies with deprivation, or about the effect of financial incentives on health inequalities in hypertension. General practices in the UK have received financial incentives for high quality care since 2004. This study set out to assess the variations in achievement of incentivised and non-incentivised quality indicators for hypertension by patient area deprivation, before and after the introduction of financial incentives.MethodsAchievement of 14 quality indicators for hypertension in 304 patient participants in 18 general practices in Norfolk, England was assessed one year before (2003) and one year after (2005) the introduction of financial incentives. Four indicators were incentivised and 10 were non-incentivised. Each participant's postcode was linked to an index of multiple deprivation score.ResultsThe range of achievement of incentivised quality indicators was 65-94% in the least deprived third of participants, and 77-94% in the most deprived third in 2003 and 2005 combined. For non-incentivised indicators, the range was 7-85% in the least deprived and 24-93% in the most deprived third.Achievement of incentivised quality indicators in 2003 and 2005 combined did not vary significantly by area deprivation. Achievement of three of 10 non-incentivised indicators was higher in participants from more deprived postcode areas: providing lifestyle advice (odds ratio 1.34, 95% confidence interval 1.00-1.79), assessment of peripheral vascular disease (1.54, 1.02-2.35) and electrocardiography (1.38, 1.04-1.82).ConclusionsParticipants from more deprived areas received at least the same, and sometimes better, quality of care than those from less deprived areas. Quality of care for hypertension in general practice may not follow the inequitable distribution seen with some other conditions.

An assessment of peripheral vascular disease in patients with diabetic foot ulcer

Background Peripheral vascular disease (PVD) is a chronic limb ischaemia caused by atherosclerosis of the peripheral arteries. Diabetes mellitus is a risk factor for this disease. The most common symptom of PVD is muscle pain in the lower limbs on exercise. In diabetes, pain perception may be blunted by the presence of peripheral neuropathy. Therefore, a patient with diabetes and PVD is more likely to present with an ischaemic ulcer or gangrene than a patient without diabetes. The use of ankle-brachial-pressure index (ABI) in the clinic and bedside provide a measure of blood flow to the ankle. This could help early detection, initiate early therapy and may thus reduce the risk of critical limb ischaemia and limb loss. Objective The purpose of this study is to evaluate the occurrence of peripheral vascular disease using ankle-brachial index in diabetic patients with and without foot ulcers and the risk factors associated with diabetic foot ulcer (DFU). Method This prospective study involved all type 2 DM patients with foot ulcer (DFU population) and those without foot ulcers (non-DFU population) seen in our hospital. Their demographic, clinical and laboratory parameters were noted and documented. Measurement of ABI was done using a portable hand held Doppler and ankle pressures < 0.9 is suggestive of PVD. Results A total of 74 patients were recruited. Males were 42 (56.8%) and females were 32 (43.2%). The mean age of the patients was 62.89 ± 10.66 years and the duration of diabetes was 7.61 ± 7.57 years. Forty-six (62.2%) presented with foot ulcer while 28 (37.8%) were without foot ulcer. Patients with PVD represented by ABI < 0.9 was DFU 31(76.4%) while in non-DFU it was 10 (13.4%). Multivariant analysis of variables associated with DFU in those with ABI < 0.9 showed correlation with tobacco use r = .235, p = 0.044; duration of diabetes r = −.427; p = 0.001; and systolic blood pressure r = −.301; p = 0.009. Discussion The occurrence of PVD determined by the absence of >2 pulses by palpation alone and using ABI was 25.7% and 55.4% respectively. This suggests that assessment by palpation is subjective while the use of Doppler is quantitative and more reliable. DFU patients with PVD showed a significant correlation with tobacco use, duration of diabetes and systolic blood pressure but not with dyslipidaemia. Conclusion This study shows that these patients had risk factors for PVD. The use of hand held Doppler will aid early diagnosis of critical limb at risk of loss and help to prevent and reduce the high rate of limb loss in our patients.

The role of CT and MRI in the assessment of peripheral vascular disease

Atherosclerosis is a serious health problem in developed countries and the main cause of morbidity and mortality. Treatment strategies such as surgical procedures, percutaneous catheter-based interventions or pharmacologic options depend on the accurate classification of atherosclerotic disease with respect to location, extent, and severity of arterial involvement. For this purpose, several imaging techniques are in clinical use. Due to recent improvements in scanner technology, noninvasive imaging modalities are now widely available for evaluating atherosclerotic lesions throughout the body. This article focuses on the clinical role of these imaging modalities in the assessment of peripheral vascular disease, including the aorta and extracranial arteries.

The ankle–brachial index in clinical decision making

Background The ankle–brachial index (ABI) is an important tool for assessment of peripheral vascular disease. Diverse methods/equations for determining the ABI have been reported as well as different cut-off values used to indicate the presence of vascular pathology. Objectives (i) Investigate the role of the brachial component to determine the ABI, and (ii) investigate the influence of different lower cut-off values. Method Three methods/equations of utilising the brachial value were used to determine the ABI of 522 individuals. Ankle blood pressure readings were divided by: (i) average of the left and right brachial reading (AVERAGE); (ii) highest of left and right brachial reading (HIGHEST); (iii) higher brachial pressure was used unless the brachial pressures differed by less than 15 mmHg between the right and left side in which case the average was used (PROVISO). For these three methods/equations cut-off points were set at 0.8. 0.9 and 1.0. Data were analysed using one-way analysis of variance for continuous data and χ 2 analysis for categorical data. Results Comparison between the three methods/equations used to determine the ABI showed a statistically significant difference between the AVERAGE and HIGHEST method/equation ( p = 0.005). Further, varying the cut-off values for each of the methods also showed statistically significant differences ( p < 0.001). Conclusion Evidence-based data are currently insufficient for development of peripheral vascular diagnostic guidelines. Our research indicated that the method and cut-off value chosen for the ABI can lead to statistically significant differences in the number of people identified with possible peripheral vascular disease.

Pulse wave from transit ratios in the assessment of peripheral vascular disease.

This paper presents a ratio of the pulse wave form transit times in the proximal and distal arterial tree, produced by a simple, non-invasive, repeatable and reproducible technique. It has been shown to be highly significant in separating normal from disease states and the proximal from the distal lesion. It has been shown to be independent of the effects of age. In the clinical situation the ratio is of value in the initial assessment of the patient (by separating ischaemic from now-ischaemic limb pain); in elucidation of significant occult proximal lesions in the presence of distal disease; in indicating the type of angiography required (femoral arteriography rather than translumbar aortography in suitable subjects); in following the progress of patients in operative and conservative management régimes; and in the long term follow-up of the natural history of obliterative vascular disease.

Transcutaneous oxygen measurements: Implications for nursing

Transcutaneous oxygen measurement is a noninvasive diagnostic technique that records the partial pressure of oxygen at the skin surface. This measurement provides information regarding the supply and delivery of oxygen to the underlying microvascular circulation. It can be used for adults in wound evaluation, hyperbaric therapy, plastic surgery, amputation level determination, and peripheral vascular disease assessment, including the status of limb revascularization procedures. This article presents an overview of transcutaneous oxygen measurement and situations that influence measurement levels, including environmental, dermal, physiologic, and mechanical factors. Nursing considerations and indications for further research are also discussed. (J Vasc Nurs 2001;19:55-61)

Assessment of peripheral arterial vascular disease with radionuclide techniques

Various radioisotopic imaging techniques for noninvasive detection of vessel stenosis and for functional investigation of reduced blood flow and follow-up have been developed during the last decade in peripheral vascular disease (PVD), with the aim of replacing invasive techniques and complementing standardized methods. Radionuclide assessment of PVD is divided into 2 major groups: imaging of perfusion and metabolic investigations. The measurement of arterial blood flow and muscle perfusion is intended to show the morphology, to evaluate the functional consequences of PVD, and to quantify the latter. The application of radiolabeled tracers was developed as a noninvasive alternative to angiography in morphologic imaging. Treadmill testing has been used to assess the functional effects of reduced blood flow in PVD where the onset of pain indicates the stage of disease, but the results can be confused by other symptoms. Scintigraphic measurement of muscle perfusion should detect insufficient nutritional blood flow in peripheral muscle and thus have a higher specificity for PVD than treadmill testing alone. Although there are very promising theoretical and experimental data in animals, the clinical use of radionuclide investigations is limited by different technical problems, such as methodologic differentiation between skin and muscle perfusion, the lack of controlled and prospective studies, and incomplete correlation with other standardized routine techniques. Among the great number of radioisotopic metabolic imaging techniques, only radiolabeled platelets and lipoproteins, to some extent, have shown a limited potential clinical use. Some other approaches seem to have a high potential from a theoretical point of view. They are limited, however, by a great number of problems. Correlation with sonographic or magnetic resonance imaging (MRI) findings may identify a potential metabolic value. Correlation with angiography reflecting the extent of the disease makes no sense. So far with PVD, neither radioisotopic perfusion studies nor metabolic imaging techniques are able to achieve a level of routine application or wider meaningful interpretation of the clinical condition of a specific patient. Competing techniques are easier to perform, less expensive, faster, more widely available, and do not carry the radiation burden. Positron emission tomography is still in its early stages of application, with great theoretical potential but at a high price. A great deal of work is still required to transform in vitro and experimental experience into more meaningful routine radioisotopic investigations in patients with PVD.

Assessment of peripheral vascular disease in diabetes. Report and recommendations of an International Workshop sponsored by the American Heart Association and the American Diabetes Association 18-20 September 1992, New Orleans, Louisiana

Recognizing the considerable excess burden of both cerebrovascular disease and LEAD suffered by individuals with IDDM or NIDDM (1,2), a workshop was convened to 1) provide a current review of the knowledge pertaining to the prevalence, incidence, and risk factor associations of cerebrovascular disease and PVD in diabetes, and 2) review and make recommendations about the methodology for identifying and quantifying LEAD in both clinical and research settings.

Leg muscle scintigraphy with 99Tcm-MIBI in the assessment of peripheral vascular (arterial) disease

A technique for using 99Tcm-methoxyisobutylisonitrile (MIBI) to evaluate leg muscle perfusion in the assessment of peripheral vascular disease (PVD) is described and evaluated. The uptake of MIBI in muscle groups is quantified and normalized to whole body activity. Eleven patients with PVD undergoing angiography and nine controls were studied. There was a significant difference in MIBI uptake in the calf (P less than 0.000 01) and thigh (P less than 0.0001) between the two groups on exercise. The technique has a sensitivity of 91% and specificity of 94% for the diagnosis of PVD. The technique can also effectively evauate the severity of disease as shown by significant correlations between exercise calf flow and angiographic severity (P less than 0.05) and Doppler ankle/arm pressure measurements (P less than 0.0005). Single photon emission tomography (SPET) of the calves was also performed in five controls and five patients with PVD. Uptake was significantly reduced in all muscle areas in patients with PVD and, amongst those with PVD, uptake was lower in muscle groups by occluded arteries. The potential role of 99Tcm-MIBI in the assessment of PVD and its advantages over other methods of assessment are discussed.

Leg muscle scintigraphy with 99Tcm-MIBI in the assessment of peripheral vascular (arterial) disease

Summary A technique for using 99Tcm-methoxyisobutylisonitrile (MIBI) to evaluate leg muscle perfusion in the assessment of peripheral vascular disease (PVD) is described and evaluated. The uptake of MIBI in muscle groups is quantified and normalized to whole body activity. Eleven patients with PVD undergoing angiography and nine controls were studied. there was a significant difference in MIBI uptake in the calf (P<0.000 01) and thigh (P<0.0001) between the two groups on exercise. The technique has a sensitivity of 91% and specificity of 94% for the diagnosis of PVD. The technique can also effectively evaluate the severity of disease as shown by significant correlations between exercise calf flow and angiographic severity (P<0.05) and Doppler ankle/arm pressure measurements (P<0.0005). Single photon emission tomography (SPET) of the calves was also performed in five controls and five patients with PVD. Uptake was significantly reduced in all muscle areas in patients with PVD and, amongst those with PVD, uptake was lower in muscle groups by occluded arteries. The potential role of 99Tcm-MIBI in the assessment of PVD and its advantages over other methods of assessment are discussed.

Application of a New Method of Limb Blood Flow Measurement Using a Radioactive Isotope and a Gamma Camera

The aim of this paper is to report our early experience using this technique in the assessment of peripheral vascular disease. In particular we describe its application in a large group of patients with intermittent claudication. These have been subdivided into two groups: those who could and those who could not successfully complete a treadmill test. We also describe its use in a group of patients with ischemic rest pain

Raised Ankle/Brachial Pressure Index in Insulin‐treated Diabetic Patients

The ankle/brachial blood pressure index (A/B PI) is important in the vascular laboratory assessment of peripheral vascular disease. However it is falsely elevated in diabetes, hence underestimating the true severity of disease. We have therefore examined the influence of diabetes on the A/B PI in 2092 patients, 538 with diabetes, all referred for evaluation of peripheral vascular disease. The prevalence of a raised A/B PI (greater than or equal to 1.5) in insulin-treated patients (18.3%) was much higher (p less than 0.001) than that in both non-insulin-treated diabetic patients (4.5%) and patients with no diabetes (2.8%). Insulin-treated patients with a duration of diabetes of greater than 30 years had a higher prevalence of raised A/B PI than those with a duration of less than or equal to 9 years. No significant age effects were seen.

Variability and reproducibility of transcutaneous oxygen tension measurements in the assessment of peripheral vascular disease.

Transcutaneous oxygen tension (TcPO2) was measured according to a standard protocol in 43 limbs from 23 subjects, by use of oxygen-sensing electrodes attached to the chest (at a single site) or dorsum of the foot (at proximal and distal sites, located 1-2 cm apart). With the subjects supine, distal foot TcPO2 differed from proximal by an average of +/- 7.4 mmHg, and in 80% of all limbs the differences were between -6 mmHg and +15 mmHg. The two TcPO2's were subsequently combined to yield a single "average" value for each foot. TcPO2 measurements were repeated twenty-four to forty-eight hours later; in the supine position the change in "average" foot TcPO2 from the first to second measurement was +/- 6.9 mmHg, and in 80% of limbs the changes were between -11 mmHg and +9 mmHg. Similar reproducibility data were also obtained for ankle/brachial blood pressure indices (ABIs), chest TcPO2, and foot TcPO2 during three minutes of leg elevation at 30 degrees. The authors conclude that: (1) TcPO2 measurements from adjacent areas on the dorsum of the foot usually differ by 20-25% or less and (2) the short-term reproducibility of TcPO2 between studies is comparable to that for ABIs.

Noninvasive assessment of peripheral vascular disease by color flow Doppler/two-dimensional ultrasound

The development, in 1985, of phased array scanning in a linear format 1 established the potential for acquiring high quality color flow Doppler (CFD) maps of the vasculature in the lower extremities. Subsequently, however, little information has been published 2,3 describing examination of the peripheral arteries by CFD, whether in linear, sector or anular format. Accordingly, the present study was undertaken to evaluate the utility of CFD in combination with 2-dimensional ultrasound (2DU) for the assessment of peripheral vascular disease.